=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699559781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TELEFAMILYDOC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2023
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15195 NATIONAL AVE STE 205
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95032-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-345-5494
-----------------------------------------------------
Fax | 623-666-6760
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 481 N SANTA CRUZ AVE STE 130
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95030-5300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-345-5494
-----------------------------------------------------
Fax | 623-666-6760
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ALEX MIRABADI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 408-354-6760
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------